Author Information
Bhate A*, Bhate M** , Chitnis S***
(* Director, ** Consultant, Shubhdeep Nursing Home, Andheri(West), Mumbai. *** Consultant, Department of Obstetrics & Gynaecology, MaxCure Superspeciality, Jogeshwari (East), Mumbai)
Abstract
Fallopian tube torsion is a rare cause of acute abdomen. It may masquerade as ovarian or cyst torsion, posing a diagnostic challenge. Diagnosis is made only intra-operatively during laparoscopy or laparotomy. We present a case of isolated fallopian tube torsion presenting as repeated episodes of acute pain in abdomen, eventually requiring salpingectomy.
Introduction
Fallopian tube torsion is a rare cause of acute abdomen. It may be associated with adjacent cysts, hydrosalpinx, pregnancy or past pelvic surgery.[1] Timely diagnosis and early operative intervention can prevent salpingectomy and preserve fertility. Ultrasound and Doppler studies should be done in all cases of acute abdomen presenting in emergency.[2] In selected cases where patient is stable, MRI may be done. Signs such as whirlpool sign and plicae tubaliae are frequently seen and may help in clinching the diagnosis.[3]
Case Report
A 36 year old multipara woman presented to emergency with acute severe pain in right flank & right groin and nausea. An urgent ultrasound revealed normal uterus and bilateral polycystic ovaries. A 5.3x3.1x4.3 cm multicystic lesion, was seen separate from ovaries. No abnormal vascularity or calcification was seen. Tumor markers and beta hCG were normal. She was put on intravenous analgesics and spasmolytics. After her pain subsided, she was discharged on oral NSAIDs. She returned to emergency after one month with similar acute pain with guarding and rigidity. She was admitted and a CT scan was done, which showed a 4x3 cm benign right ovarian cyst. Decision for diagnostic followed by operative laparoscopy, if required was taken. On pre-operative evaluation, she was stable with pulse of 90 beats/ min, and blood pressure of 100/70 mm of Hg. She had no co-morbidities. Her pre-operative investigations revealed no abnormality.
Peritoneal access was gained by supra umbilical and lateral ports. Isolated torsion of right fallopian tube with 3 twists and terminal hydrosalpinx was noted. Left fallopian tube, uterus and bilateral ovaries were normal. Right salpingectomy was done. There were no intra-operative complications and she recovered uneventfully. She was discharged on day 4 of surgery.
Figure 1. Torsion of right fallopian tube with 3 twists and a terminal hydrosalpinx
Figure 2. Final intra-operative picture after right salpingectomy
Discussion
Isolated fallopian tube torsion is a very rare finding with an incidence of 1 in 15,00,000 females. It is more common on right side.[4] Most of the cases reported worldwide are in women of reproductive age group.[5] Infrequently, it may be seen in pre-pubescent girls or post-menopausal women. At present, there are no clinical features, laboratory or imaging features pathognomonic of this condition. Acute pain in abdomen with gastrointestinal symptoms may be presenting features. Rarely, it may present as primary infertility in adult women without any acute symptoms.[6] Patient may have positive peritoneal signs, tachycardia, and or leukocytosis.[7] Preoperative ultrasound usually shows heterogeneous cystic adnexal mass with variable free fluid. Early laparoscopy is the gold standard for diagnosis and management.[1]
In our case, endoscopic intervention was delayed as patient had pain relief after spasmolytic administration. When she came back to emergency with same complaints as her previous episode, she was admitted under physician’s care. When cause of pain could not be ascertained, gynecology reference was made and decision for diagnostic followed by operative laparoscopy, if required was taken. Imaging studies had not shown any evidence of torsion and diagnosis was made intra-operative. Owing to necrotic changes and completion of child-bearing, salpingectomy was done.
Isolated fallopian tube torsion is an intraoperative finding and cannot be diagnosed clinically. Hence, it is important that early laparoscopy be planned in cases with acute abdomen in which diagnosis cannot be ascertained clinically and radiologically. An early surgical intervention can aid in diagnosis, treatment and prevention of complications. It becomes more important when patient is a young woman, where preservation of fertility is a concern.
References
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- Gunal YD, Bahadir GB, Boybey O, Cil AP, Aslana MK. A rare cause of acute abdominal pain in children: Isolated tubal torsion; a case series.Turk J Emerg Med. 2017 Jun; 17(2): 73–76.
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- Toyoshima M, Mori H, Kudo K, Yodogawa Y, Sato K, Kudo T, et al. Isolated torsion of the fallopian tube in a menopausal woman and a pre-pubertal girl: two case reports. J Med Case Rep. 2015;9:258.
- Murphy EM, Pereira N, Melnick AP, Spandorfer SD. Spontaneous bilateral torsion of fallopian tubes presenting as primary infertility. Womens Health (Lond). 2016; 12(3): 297–301.
- Wong SW, Suen SH, Lao T, Chung KH. Isolated fallopian tube torsion: a series of six cases. Acta Obstet Gynecol Scand. 2010;89(10):1354-6.
Bhate A, Bhate M , Chitnis S. Laparoscopic Approach In Rare Case Of Isolated Fallopian Tube Torsion. JPGO 2017. Volume 4 No.8. Available from: http://www.jpgo.org/2017/08/laparoscopic-approach-in-rare-case-of.html